AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | Prevalence of female genital schistosomiasis in women with abnormal Pap smears at King Edward VIII Hospital, KwaZulu-Natal 14 30 2 Pos CD4=779 HSIL CIN III, HPV changes, chronic cervicitis, Schistosoma Ova 15 30 1 Pos CD4=446 HSIL CIN III, HPV changes, Schistosoma Ova 16 31 3 Neg HSIL CIN III, HPV changes, Schistosoma Ova 17 43 4 Neg HSIL CIN III, HPV changes, chronic cervicitis, scattered Schistosoma Ova 18 31 2 Neg HSIL CIN III, HPV changes, Schistosoma Ova 19 28 2 Neg HSIL CIN II, HPV changes, Schistosoma Ova DISCUSSION The current study found a 2.09% prevalence of FGS confirmed by histology samples, with no schistosomal infections detected via Pap smears. Our findings align with another local study reporting a 2% detection rate via Pap smears and 23% in urine samples 7 . These findings corroborate that Pap smears perform poorly in diagnosing FGS. While this prevalence seems low, it is important to note that our study focused on an urban population, residing mainly in areas in and around Durban. Higher prevalence rates have been reported in endemic KwaZulu-Natal districts. Previous studies using urine analysis among primary and secondary school participants in endemic districts of KwaZulu-Natal such as Ugu and iLembe found prevalence rates between 10% and 49% 3 . Another study found haematuria indicative of urogenital schistosomiasis in 39% of girls (95% CI: 37-41) in iLembe Health District and 56% (95% CI: 50-56) in uThungulu Health District 8 . To date, no local study has correlated histologically diagnosed FGS in women with cervical dysplasia. In the current study, cytology misdiagnosed 5 out of 19 patients (26%) as having some form of SIL. Specifically, 4 were misdiagnosed with HGSIL and 1 with SIL, while histology revealed no atypia or dysplasia. Cytological features of cervicitis may resemble squamous intraepithelialneoplasticchanges,potentiallyleadingtoconfusion between these two conditions. The presenting symptoms such as irregular bleeding, pain during sexual intercourse, malodorous vaginal discharge, and pelvic pain, may be misdiagnosed as STIs. Patients are often treated multiple times without resolution of symptoms 7,9 . It is worth noting that patient number 5 was 28 years old and HIV-negative. She may have been offered a Pap smear due to persistent symptoms, as it is not standard practice to perform cervical screening for women under 30 who are not living with HIV 10 . However, the policy does recommend screening forwomen with persistent lower genital tract symptoms. Chronic cervical inflammation was found in 5 patients (26.3%) of the FGS group. The presence of ova is responsible for inducing a granulomatous reaction in the host, leading to chronic inflammation 11 . Therefore, women with persistent vaginal discharge should be offered further clinical evaluation, which may include a Pap smear (shown to have poor sensitivity in this case) and colposcopy. The latter should be performed by a clinician trained in identifying FGS features. Studies have shown that alternative methods for detecting Schistosoma, such as cervicovaginal lavage (CVL) PCR and urine microscopy, have lower detection rates compared to colposcopy examination. Colposcopic findings include homogeneous yellow sandy patches, grainy sandy patches, firm rubbery papules, and abnormal blood vessels 12,13 . However, most practitioners, including gynaecologists, lack training in identifying these lesions 14 . Urine microscopy, which has been used as a screening test in most FGS studies, has a sensitivity of 34.7% and a specificity of 75.2%. A more comprehensive approach, the latent-class analysis (LCA), incorporates colposcopy findings and reported urogenital symptoms. This method demonstrates improved accuracy, with a sensitivity of 81.0% and a specificity of 85.6% 15 . The HIV prevalence among women with FGS was 26.3%, compared to 39.8% in the larger group without FGS. This lower rate in women with FGS contradicts local data suggesting that FGS may predispose women to acquiring HIV 16 . Around the time of the study, Eaton et al., 2014, reported that the HIV prevalence among adult non-pregnant females was 24% (95% CI: 4-45), which is significantly lower than in this study 17 . However, it is important to note that most women screened for cervical cancer are primarily from antiretroviral (ARV) clinics, which might explain the higher HIV rate in this cohort. Local immune reactions, in addition to genital lesions such as ulcers and other STIs, may increase the risk of HIV infection 18 . All women diagnosed with FGS showed Schistosoma ova, with schistosome worm found in only one case. Histological diagnosis primarily relies on egg detection. Schistosomal eggs develop in tissues over 5 to 6 days, secreting a glycoprotein that triggers the host's inflammatory response 19 . The schistosomal life cycle involves two hosts: the Bulinus snail and mammals (humans). Asexual reproduction occurs in snails, while sexual reproduction takes place in humans. Snails release cercariae into freshwater, which penetrate human skin and develop into schistosomula. These grow into adult worms, relocating to the bladder and ureters to produce eggs 2 . During the chronic phase lasting several months, eggs either exit the body via urine or become trapped in tissues. Trapped eggs die, calcify, and elicit an inflammatory response, forming granulomas detectable by diagnostic methods 20 . In contrast to the eggs, the live worms do not cause significant inflammation nor impede haemostasis 21 . The World Health Organization (WHO) developed a 2021- 2030 road map for neglected tropical diseases after extensive consultations, aiming to end the neglect and achieve sustainable development goals. The COVID-19 pandemic response demonstrated that collaboration across different sectors can be powerful 22 . FGS is a preventable disease. Mass administration of praziquantel is a proven, cost-effective method to reduce the prevalence and burden of this disease. Formulations suitable for young children may prevent the onset of genital lesions that lead to FGS23. StudyLimitations: The study had several limitations. Colposcopy findings were excluded because available data did not include details such as margins, color, vessels, and iodine staining. Instead, only HPV changes, CIN grade, and excision status were noted. We chose to disregard colposcopy findings because most clinicians are not familiar with FGS lesions on colposcopy. Additionally, the single-center design may limit the generalizability of the findings to the broader population. The study also excluded women with histological cancer (or cancer in situ), which probably African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 2 | 2025 | 19